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Background: Despite advances in surgical techniques and various implants, the treatment of intra-articular distal femoral fractures poses a challenge to the clinicians worldwide. In this study we aimed to evaluate the clinical outcomes of lateral locking plate combined with medial assisted plate for treating intraarticular comminuted distal femoral fractures. Materials and Methods: We conducted a retrospective study which consisted of 10 cases of distal femur fracture with intraarticular extension and treated with open reduction and internal fixation with dual column plating using single incision anterior midline approach. Results: The mean age was 40.75±12.39 with a range of 20-70 years. There were 7 males and 3 females. Mean time for union was 16.15±1.35 weeks. 1 patient had decreased ROM due to stiffness at the knee joint. 1 patient had superficial infection. No deep infection was noted. 1 case of non-union was noted in this study. Range of motion at knee at final follow up was 124.25±17.34 degrees. The mean NEER score was 82.15±9.19 with a range of 54-91. Conclusion: Single-incision dual plating approach for distal femoral fractures is effective and provides stable construct without loss of reduction and allows early rehabilitation and good functional outcomes.

Background Data: Cauda equina syndrome (CES) is a rare situation and is one of the few surgical emergencies in neurosurgery. While L4-L5 disc is the most common cause of CES, ependymoma and schwannoma are the most common tumors affecting cauda equina. Purpose: To present our experience and outcome of management of cauda equina tumors. Study Design: A retrospective clinical case study. Patients and Methods: We operated upon 22 cases with known cauda equina tumors at our institution in the period between October 2016 and April 2020. All patients were subjected to detailed general, neurological, and radiological evaluation both preoperatively and postoperatively according to our follow-up protocol. Moreover, the modified McCormick scale (MMS) has been used for pre- and postoperative functional evaluation. Patients underwent operation using the posterior midline approach, with neuromonitoring applied in 50% of patients. Results: The mean age was 44 ± 12.5 years. Nine (41%) patients were female and 13 (59%) were male. Ninety-one percent of patients presented with radiculopathy. Fifty percent of cases presented with schwannoma. Growth total tumor resection was achieved in 20 cases (91%). The last follow-up showed marked improvement in radiculopathy, motor power deficit, and MMS compared to preoperative values. Immediate postoperative motor power deterioration was reported in two cases. Recurrence was reported in one case of ependymoma at a two-year follow-up visit that underwent operation with no further recurrence after 1-year follow-up. Conclusion: The data of this study may suggest that most cauda equina tumors are benign and favorable outcome could be achieved in small-sized lesions with a short history and good preoperative clinical status. (2020ESJ220)

Posterior spinal instrumentation and fusion is the gold standard of surgical treatment for adolescent idiopathic scoliosis (AIS). This procedure is conventionally performed open, through a posterior midline approach. Minimally invasive spinal surgery (MIS) has been found to be associated with decreased blood loss, shorter duration of hospital stays, earlier mobilization, and decreased analgesic requirements in other areas of spinal surgery. In the treatment of patients with AIS, these principles can be applied via a posterior MIS approach and an anterior thoracoscopic approach. This article aimed to provide an overview of the current state of knowledge of MIS for AIS surgery. We will describe the rationale for the use of posterior MIS for AIS, a description of the surgical technique and a discussion of the current evidence for its use. We will also describe the indications, surgical technique, and evidence for MIS anterior spinal fusion as a definitive procedure for AIS and for non-fusion convex growth modulation procedures.

BACKGROUND Concern has been raised that Sprotte needles predispose to spinal anes-thesia failure. Nevertheless, these needles are associated with a low incidence of postdural puncture headache. The impact of the paramedian approach to postdural puncture headache remains controversial. The objective of this prospective randomized study was to compare Sprotte, Quincke and Atraucan needles as well as the midline and the paramedian approach in terms of postdural puncture headache and spinal anesthesia failure in patients undergoing Caesarean section. METHODS 655 patients were randomized to 5 groups. A midline approach was used in four groups. The spinal needles were the 25G Sprotte, 27G Sprotte, 26G Atraucan and 25G Quincke. In the fifth group a 25G Quincke needle was used by the paramedian approach. RESULTS The incidence of postdural puncture headache was 0% in both 25G and 27G Sprotte groups, 2.5% in the 26G Atraucan group, and 7.2% and 2.7% in the 25G Quincke midline and paramedian approach respectively. A significant difference in terms of postdural puncture headache was found between 25G Sprotte and 25G Quincke needles (P = 0.004), while the failure rate was similar between these two needles. A significant difference in spinal anesthesia failure rate was observed between midline and paramedian approaches (P = 0.041). CONCLUSIONS Sprotte but not Atraucan needle design correlates with lower incidence of postdural puncture headache compared to Quincke design. Sprotte needles are not associated with a higher spinal anesthesia failure compared to Quincke needles. The incidence of postdural puncture headache by the paramedian approach is not significantly reduced whereas the spinal anesthesia failure rate is increased in comparison to the midline approach.

Introduction Favorable short-term outcomes have been reported following muscle-preserving interlaminar decompression (MILD), a less invasive decompression surgery for lumbar spinal canal stenosis (LSCS). However, there are no reports of mid- to long-term outcomes. The purpose of this study was to evaluate the clinical outcomes five or more years after treatment of LSCS with MILD. Methods Subjects were 84 cases with LSCS (44 males; mean age, 68.7 years) examined five or more years after MILD. All patients had leg pain symptoms, with claudication and/or radicular pain. The patients were divided into three groups depending on the spinal deformity: 44 cases were without deformity (N group); 20 had degenerative spondylolisthesis (DS group); and 20 had degenerative scoliosis (DLS group). The clinical evaluation was performed using Japanese Orthopedic Association (JOA) scores, and revision surgeries were examined. Changes in lumbar alignment and stability were evaluated using plain radiographs. Results The overall JOA score recovery rate was 65.5% at final follow-up. The recovery rate was 69.5% in the N group, 65.2% in the DS group, and 54.0% in the DLS group, with the rate of the DLS group being significantly lower. There were 16 revision surgery cases (19.0%): seven in the N group (15.9%), three in the DS group (15.0%) and six in the DLS group (30.0%). There were no significant differences between pre- and postoperative total lumbar alignment or dynamic intervertebral angle in any of the groups, slip percentage in the DS group, or Cobb angle in the DLS group. Conclusions The mid-term clinical results of MILD were satisfactory, including in cases with deformity, and there was no major impact on radiologic lumbar alignment or stability. The clinical outcomes of cases with degenerative scoliosis were significantly less favorable and the revision rate was high. This should be taken into consideration when deciding on the surgical procedure.

Introduction: Removal of intracranial supra-sellar masses continues to be a surgical challenge. Various approaches have been used by different authors with varying results. Anterior basal interhemispheric approach is most suitable with better results than other approaches for craniopharyngiomas Materials and methods: Fifteen patients with large craniopharyngiomas having third ventricular and or retro or supra-sellar extensions or reaching the interpeduncular cisterns were operated by this approach, over a period of seven years since the first use of this approach at our institute. The data of patients opearated by this approach were then retrospectively analysed. There were eleven males and four females with five patients in the pediatric age group. Follow up range was from 2 to 83 months with a mean of 21.6 months. Results: Total excision was achieved in seven (46.6%) and near total excision in another seven (46.6%), partial excision was done in only one (6.66%). Seven patients with total excision were disease free at mean follow up of 6.8 months. There was asymptomatic recurrence in two (13.33%) patient with near total excision at 11 and 63 months respectively and were given radiotherapy post-operatively. All patients were symptom free except one with diabetes insipidus (DI) and one mortality, and one with post operative visual deterioration. Conclusion: Anterior basal interhemispheric approach is a useful alternative to other transcranial approaches in the management of the craniopharyngiomas. It has the advantage of being a midline approach and displays the tumour brain interface better. Keywords: Intracranial, transcranial, craniopharyngiomas

Introduction: Thoracolumbar fractures account for approximately 20% of fractures of the spinal column, the majority of which are unstable. In terms of management the aims proposed are to prevent further neurological injury, decompress the spinal canal in the presence of canal stenosis, and stabilize the spine. Materials and methods: We performed a prospective cohort study of 32-patients who presented to the Department of Orthopaedics, Lahore General Hospital, in Pakistan, from the 01 April 2018–31 March 2019, with unstable thoracolumbar fractures that were operatively stabilized. Sixteen subjects underwent a mini-open muscle splitting Wiltse approach (Cohort A), and 16-subjects underwent a traditional open midline approach (Cohort B). The data captured and analysed in this study included subject age; gender; type of surgical approach performed; length of operative procedure; volume of intra-operative blood loss; and amount of post-operative thoracolumbar pain assessed by the Visual Analogue Pain Scale Score. Results: The mean age of subjects in Cohort A was 36 ± 9.7 years, and the mean age of subjects in Cohort B was 36 ± 8.0 years. The male to female ratio was 1.7:1 in Cohort A, and 2.2:1 in Cohort B. Considering duration of surgery, a significant difference was demonstrated between Cohort A and Cohort B, favouring a shorter duration of surgery in Cohort A (p

This is an updated version of a clinical decision making article originally published in Vet Record in June 2018.7 #### Bottom line Dr Perry brings her five-month-old female domestic shorthair kitten, Kylie, in to be spayed. She has read on the internet that cats can be spayed using either a midline or a flank incision. She is very concerned about Kylie being in pain and asks you which is the least painful surgical option for Kylie. You wonder if one approach is less painful than the other. In \[female cats that are being neutered] does [a midline approach compared with a flank approach\] \[decrease pain following surgery\]? The search strategy can be viewed at https://bestbetsforvets.org/bet/567, and it is also available as a supplement to this article on Vet Record ’s website at https://veterinaryrecord.bmj.com/content/186/17/565 ### Supplementary data [vetrecm2008supp001.docx] Search last performed: 24 April 2020 Only five of the six papers identified were evaluated for this evidence summary. Coe et al 1 contains the same data set as Grint et al , …

C2 schwannomas are rare lesions that may develop in the spinal canal, in the area of the C2 ganglion situated posterior to the C1C2 articulation, in the extraspinal area or in a combination of these 3 sectors.1,2 The surgical removal of these lesions is delicate because of the intimate relationships the schwannomas develop with the V3 segment of the vertebral artery. A variety of lateral, far-lateral, or extreme lateral approaches have been described in order to tackle these lesions. We use a posterior midline approach that takes advantage of the predominantly extradural development of C2 schwannomas. In this technique, the main step is the debulking of the posterior articular sector of the tumor, which is easily accessible through a midline posterior approach and necessitates minimal bone removal. In most cases, removal of the homolateral posterior arch of C1 is sufficient in order to create an adequate access. These maneuvers create the necessary space for dissecting both the intradural and extraspinal sectors of the schwannoma. We present this technique through a case with a minimal intradural component exerting mainly a lateral compression of the spinal cord. The tumor was operated through the midline mini-invasive posterior approach with a favorable result. We demonstrate the surgical technique in video and discuss the nuances.

BackgroundSpinal anesthesia using the midline approach might be technically difficult in geriatric population. We hypothesized that pre-procedural ultrasound (US)-guided paramedian technique and pre-procedural US-guided midline technique would result in a different spinal anesthesia success rate at first attempt when compared with the conventional landmark-guided midline technique in elderly patients.MethodsIn this prospective, randomized, controlled study,one hundred-eighty consenting patients scheduled for elective surgery were randomized into the conventional surface landmark-guided midline technique (group LM), the pre-procedural US-guided paramedian technique (group UP), or the pre-procedural US-guided midline technique (group UM) with 60 patients in each group. All spinal anesthesia were performed by a novice resident.ResultsThe successful dural puncture rate on first attempt (primary outcome) was higher in groups LM and UM (77 and 73% respectively) than in group UP (42%;P P P P ConclusionsA pre-procedural US scan did not improve the ease of midline and paramedian spinal anesthesia as compared to the conventional landmark midline technique when performed by junior residents in elderly population.Trial registrationRetrospectively registered at Clinicaltrials.gov, registration numberNCT02658058, date of registration: January 18, 2016.

Summary: Introduction: The traditionally taught technique for conventional open thyroidectomy is via a midline splitting of the strap muscles following a skin crease neck incision – midline approach (MA). The lateral “backdoor” approach (LA) uses the same central neck incision but approaches the thyroid gland between the anterior border of sternocleidomastoid (SCM) and strap muscles. This technique is usually reserved for re-do thyroid surgery. We compared the results of the two approaches in patients undergoing conventional thyroidectomy for the first time. Methods: A case-control study was performed on 90 patients undergoing conventional open thyroidectomy from 2012 to 2014. The first 45 patients underwent MA and subsequent 45 patients underwent LA. All patients were given 10 ml of 1% Marcaine infiltration into the neck incision before closure. Basic demographic data, operative time, incision length, weight of gland, need for transection of strap muscles and complications were recorded. Revision thyroid surgery and minimally invasive thyroid operations were excluded. Results: The demographics, operative timing, gland weight and incisional length showed no significant difference. Post-operative pain was significantly lower in the LA group. 5 patients (11%) in MA group needed horizontal transection of strap muscles to extract large goitres compared to 1 patient (2.2%) in the LA group. No major complications occurred in either group. Conclusion: The LA method is as safe as the midline technique with comparable operative time and significantly lower pain scores. It avoids midline separation and suturing of strap muscles and reduces the need for strap muscle transection to removal large goitres. Keywords: Lateral approach, Backdoor, Open throidectomy, Sternomastoid

Purpose: The objective of this study is to describe the removal of retained intraocular foreign body (RIOFB) by bimanual pars plana vitrectomy through midline sclerotomy in phakic patients. Technique: Four eyes with RIOFB and clear lens underwent microincision vitrectomy surgery. A chandelier illumination was placed through one of the existing ports. The foreign body (FB) was localized by direct visualization (intravitreal) or indentation (pars plana), stabilized using an intraocular magnet/FB forceps introduced through a midline sclerotomy and freed of vitreous from all sides using a vitrectomy cutter through the other port bimanually, reoriented along their long axis and extracted through the midline sclerotomy. Results: All four FBs were removed successfully without slippage or damage to the clear lens. Conclusion: Chandelier illumination-assisted removal of FB through midline sclerotomy helps in easier localization, stabilization and removal, avoiding lens touch even in anteriorly located FBs such as at pars plana.

Background and Aims: Identification of subarachnoid space in pregnant patients can pose a great challenge to anaesthesiologists. This study was designed to compare conventional landmark technique with pre-procedural ultrasonography-assisted midline approach for identification of the subarachnoid space in elective caesarean section. Methods: After institute ethics committee approval and written informed consent, 100 parturients scheduled for elective caesarean section under spinal anaesthesia were included in this prospective randomised control trial and divided into Group L (n = 50) (landmark technique) and Group U (n = 50) (ultrasound-guided technique). Parameters such as time taken for the identification of the interspace, distance between skin and dura mater, number of insertion attempts (the primary outcome), number of passes and time taken were recorded in both the groups. Statistical analysis was done using SPSS software 16. Results: Demographic profiles of both groups were comparable. The number of attempts for needle insertion (1.04 ± 0.19 vs. 1.97 ± 0.77), number of passes in the same interspinous space (1.26 ± 0.44 vs. 1.90 ± 0.51) and the total time for successful lumbar puncture (31.90 ± 6.30 vs. 51.80 ± 12.28 s) were significantly less in Group U as compared to Group L, but the time of identification of interspinous space was significantly more in Group U (56.70 ± 13.08 s) as compared to Group L (47.10 ± 10.45 s). Conclusion: Pre-procedural ultrasound is a useful tool for successful lumbar puncture in parturients as it reduces the number of attempts with fewer side effects as compared to conventional landmark technique.

Introduction: A cadaveric study for comparison of dorsal pedicular diameters in Indian males and females. Morphometric study of pedicles of spine of dorsal region is thus relevant and critical for proper placement of the transpedicular screw to avoid inadvertent penetration of pedicular wall.Material and Methods: It’s a observational study done at a tertiary health care centre in which 30 cadavers were studied using posterior midline approach. Direct measurements were taken on the vertebra with using a sliding vernier caliperResults: Thirty cadavers were studied out of which 23 were males and seven wee females. I studied vertical as well as horizontal diameter at the middle of pedicle and calculate mean of these two and did comparison between Indian males and females. When compared with males of the same height, females have thinner pedicles. This means the average diameter of the pedicular screws which is safe for the males at the particular level cannot be considered safe for females of the same height and age.Conclusion: On the basis of this study we have idea about average screw size for male and female at particular level to avoid untoward complication of current pedicular system. In males average diameter goes on increasing from D1to D12 with highest at D12 -5.6mm while lowest at D2 and D3 i.e. 4.5 mm. In females we found average diameter goes on increasing from D1to D12 with highest diameter at D9 i.e, 5.2mm and lowest at D2 i.e. 4.2 mm. As compared to the males females have thinner pedicles.

Background and Objectives Neuraxial blockade using a midline approach can be challenging. Part of this challenge lies in finding the optimal approach of the needle to its target. The present study aimed at finding (1) the optimal point of insertion of the needle between the tips of 2 adjacent spinous processes and (2) the optimal angle relative to the skin at which the needle should approach the epidural or subarachnoid space. Methods A computer algorithm systematically analyzed computed tomography scans of vertebral columns of a cohort of 52 patients. On midsagittal sections, the possible points of insertion of a virtual needle and the corresponding angles through which the epidural or subarachnoid space can be reached were calculated. Results The point chosen to introduce the needle between 2 adjacent spinous processes determines the range of angles through which the epidural or subarachnoid space can be reached. At the thoracic interspaces 1-2 through 3-4, thoracic interspaces 5-6 through 9-10, and at the lumbar vertebral interspaces 2-3 through 4-5, the optimal point of insertion is slightly inferior to the point halfway between the tips of the spinous processes. For thoracic interspace 4-5, the optimal point of insertion is slightly superior to the point halfway between the tips of the spinous processes. For the other interspaces, the optimal point of insertion is approximately halfway between the tips of the spinous processes. The optimal angle to direct the needle varies from 9 degrees at the thoracolumbar junction and at the lumbar interspaces 3-4 and 4-5, to 53 degrees at the thoracic interspace 7-8. Conclusions Our study has resulted in practical suggestions-based on accurate, reproducible measurements in patients-As to where to insert the needle and how to angulate the needle when performing neuraxial anesthesia using a midline approach.

There is no evidence that either a flank or midline approach for spaying cats is consistently associated with more wound complications, and, overall, complication rates appear to be low.

International audience; Pituitary surgery is performed via a transsphenoidal approach in the vast majority of cases according to various methods that have changed over the years. A microscopic transseptal approach via a sublabial mucosal incision or a nasal mucosal incision has also been extensively used. An endoscopic transnasal approach was first described in the 1990's, followed by the concept of a microscopic transseptal approach and an endoscopic strictly endonasal approach. We use an entirely endoscopic transseptal transsphenoidal approach via an incision in the nasal mucosa for both access and tumour resection. This procedure has a number of advantages: strictly midline approach to the sella turcica, large operative field, no interference between instruments and a low rate of nasal complications.

Mark Vogt,1 Dennis J van Gerwen,2 John J van den Dobbelsteen,2 Martin Hagenaars,3 1Department of Anesthesiology, Erasmus MC Sophia Children Hospital, Rotterdam, the Netherlands; 2Department of Biomechanical Engineering, Delft University of Technology, Delft, the Netherlands; 3Department of Anesthesiology, Canisius Wilhelmina Ziekenhuis, Nijmegen, the Netherlands Abstract: Performance of neuraxial blockade using a midline approach can be technically difficult. It is therefore important to optimize factors that are under the influence of the clinician performing the procedure. One of these factors might be the chosen point of insertion of the needle. Surprisingly few data exist on where between the tips of two adjacent spinous processes the needle should be introduced. A geometrical model was adopted to gain more insight into this issue. Spinous processes were represented by parallelograms. The length, the steepness relative to the skin, and the distance between the parallelograms were varied. The influence of the chosen point of insertion of the needle on the range of angles at which the epidural and subarachnoid space could be reached was studied. The optimal point of insertion was defined as the point where this range is the widest. The geometrical model clearly demonstrated, that the range of angles at which the epidural or subarachnoid space can be reached, is dependent on the point of insertion between the tips of the adjacent spinous processes. The steeper the spinous processes run, the more cranial the point of insertion should be. Assuming that the model is representative for patients, the performance of neuraxial blockade using a midline approach might be improved by choosing the optimal point of insertion. Keywords: neuraxial blockade, midline approach, optimal point of insertion, geometrical model

Background: Spinal anaesthesia in elderly patients is frequently associated with significant technical difficulties. Spinal anaesthesia can be given by either paramedian or median approach. Paramedian approach has been used as an alternative in case of failure with median approach. The goal of this study is to determine which of these two approaches should be preferred as a first choice of spinal anaesthesia in elderly patients. Methods: The study included 100 patients of either sex, aged 50 years and above, who received spinal anaesthesia either with the midline approach (group M, n=50) or paramedian approach (group PM, n=50). Results: The success rate of paramedian group was 100% as compared to 96 % in median group. The first attempt success rate was 90% in group PM and 70% in group M. Paraesthesia was felt in 5 patients (10%) in midline group and in 2 patients (4%) in paramedian group. Hemorrhagic tap was seen in 2 patients each in both the groups . None of the patients in Group M had postdural puncture headache (PDPH) as opposed to 2 patients in Group M. Conclusions: Thus the study conclude that paramedian approach is a better approach for spinal anaesthesia in elderly patients in terms of success rate, success at first attempt, complications like paraesthesia, PDPH and failure of sub-arachnoid block. Thus study recommends the routine use of paramedian approach for sub-arachnoid block in elderly patients as first choice.

In the original investigation entitled “Cervical Epidural Steroid Injection: Parasagittal versus Midline Approach in Patients with Unilateral Cervical Radicular Pain; A Randomized Clinical Trial.”[1] which was published in April 2019 issue of the journal, one author name has been unintentionally omitted from the final draft and the affiliations were wrongly assigned. There is an error in the author list of this article, which should be corrected as follows: “Masoud Hashemi,1 Payman Dadkhah,1 Mehrdad Taheri,1 Ebrahim Golmakani,1,2 Kasra Dehghan,1 Rouhollah Valizadeh.3”. The affiliations are also corrected as follow: “1Pain Management Fellowship, Department of Anesthesiology, Anesthesiology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran; 2Department of Anesthesiology, Mashhad University of Medical Sciences, Mashhad, Iran; 3Department of Epidemiology, Student Research Committee, Iran University of Medical Sciences, Tehran, Iran”. The article was corrected online.

Background: Lumbar spinal canal stenosis surgery has recently improved with the use of minimally invasive techniques. Less invasive procedures have emerged, and microendoscopic decompression through smaller incisions is frequently performed. Tubular surgery with the assistance of endoscopic surgery procedures has led to particularly remarkable changes in surgery, with reduced tissue trauma and morbidity. Purpose: The purpose of this study was to compare the clinical outcomes of two different minimally invasive decompressive surgical techniques (microendoscopic bilateral decompression surgery using the unilateral approach [microendoscopic laminectomy (MEL)] and microendoscopy-assisted muscle-preserving interlaminar decompression (MILD; ME-MILD)) using spinal endoscopy for lumbar spinal canal stenosis measured using a visual analog scale (VAS), the Japanese Orthopedic Association (JOA) score, and the JOA Back Pain Evaluation Questionnaire (JOABPEQ), which is based on a patient-oriented scoring system. Study design: This study was a retrospective review of prospectively collected surgical data. Methods: The study included 81 patients (MEL 39 patients, 20 men and 19 women, mean age 68.9 years; and ME-MILD 42 patients, 22 men and 20 women, mean age 73.1 years) with lumbar spinal stenosis (LSS). The indications for surgery were moderate-to-severe stenosis, persistent neurological symptoms, and failure of conservative treatment over 3 months, with a JOA score under 15 points or intermittent claudication at 100 m. This study included patients having LSS at a single vertebral level (L4/5). Results: Low back pain, buttock-leg pain, and numbness were significantly improved in terms of the VAS score from 3 months with both MEL and ME-MILD. In all periods, JOA scores over 3 years of follow-up were significantly higher than those obtained before surgery with both MEL and ME-MILD, and there were improvements of low back pain and walking function. Conclusions: These observations demonstrate that ME-MILD is a safe and very effective minimally invasive technique for degenerative LSS, similar to MEL.

Background and Aims: Routine use of pre-procedural ultrasound guided midline approach has not shown to improve success rate in administering subarachnoid block. The study hypothesis was that the routine use of pre-procedural (not real time) ultrasound-guided paramedian spinals at L5-S1 interspace could reduce the number of passes (i.e., withdrawal and redirection of spinal needle without exiting the skin) required to enter the subarachnoid space when compared to the conventional landmark-guided midline approach. Methods: After local ethics approval, 120 consenting patients scheduled for elective total joint replacements (Hip and Knee) were randomised into either Group C where conventional midline approach with palpated landmarks was used or Group P where pre-procedural ultrasound was used to perform subarachnoid block by paramedian approach at L5-S1 interspace (real time ultrasound guidance was not used). Results: There was no difference in primary outcome (difference in number of passes) between the two groups. Similarly there was no difference in the number of attempts (i.e., the number of times the spinal needle was withdrawn from the skin and reinserted). The first pass success rates (1 attempt and 1 pass) was significantly greater in Group C compared to Group P [43% vs. 22%, P = 0.02]. Conclusion: Routine use of paramedian spinal anaesthesia at L5-S1 interspace, guided by pre-procedure ultrasound, in patients undergoing lower limb joint arthroplasties did not reduce the number of passes or attempts needed to achieve successful dural puncture.

Study Design Systematic review. Clinical Questions (1) Is autologous local bone (LB) graft as safe and effective as iliac crest bone graft (ICBG) in lumbar spine fusion? (2) In lumbar fusion using ICBG, does a single-incision midline approach reduce postoperative iliac crest pain compared with a two-incision traditional approach? Methods Electronic databases and reference lists of key articles were searched up to October 2014 to identify studies reporting the comparative efficacy and safety of ICBG versus LB graft or comparing ICBG harvest site for use in lumbar spine surgery. Studies including allograft, synthetic bone, or growth factors in addition to ICBG and those with less than 80% of patients with degenerative disease in the lumbar spine were excluded. Two independent reviewers assessed the level of the evidence quality using the Grades of Recommendation Assessment, Development and Evaluation criteria, and disagreements were resolved by consensus. Results Seven studies were identified as using ICBG fusion for degenerative disease in the lumbar spine. There were no differences in the fusion, leg pain, low back pain, or functional outcomes between patients receiving LB versus ICBG. There was a higher incidence of donor site pain and sensory loss in patients receiving ICBG, with no donor site complications attributed to LB. Compared with patients with the graft harvested through the two-incision traditional approach, patients with the graft harvested through the single-incision midline approach had lower mean pain scores over the iliac crest, with a higher proportion reporting no iliac crest tenderness. In patients with ICBG harvested through the single-incision midline approach on either the right or the left side of the ilium, only 36% of the patients were able to correctly identify the side when asked whether they knew which iliac crest was harvested. Only 19% of the patients with ICBG harvested through the single-incision midline approach on either the right or the left side of the ilium reported pain that was concordant with the side that was actually harvested. Conclusions LB is as safe and efficacious as ICBG for instrumented fusion in the lumbar spine to treat degenerative disease. When ICBG is used, graft harvest through the single-incision midline approach reduces postoperative iliac crest pain compared with a two-incision approach.

We devised a tubular surgery with the assistance of endoscopic surgery via midline approach to the spinal canal to preserve the bilateral facet joints and the paravertebral muscles when treating lumbar spinal canal stenosis. We report details of this operative procedure.A 2-cm incision is made in the skin in the midline of the intervertebral level to be decompressed. The spinous process on the cranial side is partially excised, and incisions along the ligament fiber are made in the midline of the supraspinous and interspinous ligaments to expose the ligamentum flavum. After the lamina and the inferior parts of the bilateral facet joints are adequately excised, the microendoscopic discectomy system is inserted. With this procedure, no muscular tissue is seen in the surgical site. The portal approach is small, but if full advantage is taken of the spinal microendoscope's merits, the bilateral facet joints are preserved and wide decompression of deep parts is possible. The microendoscope is positioned above the spinal canal to provide a good symmetrical field of view to enable easy anatomical orientation.Bilateral intervertebral joints were satisfactorily preserved in ten patients who received this surgery. All became ambulatory on the day after surgery and the clinical results remained favorable 3 years after the operation.Tubular surgery with the assistance of endoscopic surgery via a midline approach is a minimally invasive surgical procedure with favorable results that enables preservation of paravertebral muscles and bilateral facet joints.

Summary Background and objectives Epidural approach angle is one of the determining factors for needle traveling length to reach the epidural space. Likewise, the margin of safety against accidental dural puncture should be affected by epidural approach angle because the space available for epidural needle tip movement in the epidural space is depending on the inserting angle to the epidural space. The purpose of this study is to conjecture the effect of the angle formed with the skin and an epidural needle on the margin of safety against accidental dural puncture using a mathematical model. Case report Suppose that the width of the epidural space is A mm and that the force advancing the epidural catheter is C kgf and the diameter of the catheter is D mm. In this situation, assuming that the cephalad angle with the midline approach formed with the skin and an epidural needle is θ, the following parameters can be determined: the available distance for the needle tip in the epidural space = A/sinθmm; cephalad advancing force of catheter = C*cosθ kgf; and the pressure at the site of dura matter where the epidural catheter is pushing = 400*C*sinθ.πD−2 kgf.cm−2. The longer the distance available for the needle tip, the larger the margin of safety for dura injury by the epidural needle. It is supposed that θ should be set smaller to make the margin of safety larger. Likewise, smaller θ could decrease the pushing pressure and more effectively create a distinct cephalad advancing force. Conclusions Acute cephalad angulation should be considered to increase the margin of safety for epidural approach and catheterization.

Regional anesthesia is preferred world-wide for its distinct advantages. The benefits of regional anesthesia in patients with comorbid conditions are well-established. The administration of regional anesthesia can sometimes pose a challenge to the anesthesiologist due to the structural abnormalities of the spine. The most common difficulty encountered for spinal anesthesia in our hospital (Nalgonda District) is skeletal fluorosis. Apart from the midline approach, paramedian, and Taylor's approaches are advocated for difficult scenarios. This article reports two orthopedic cases, conducted under a novel spinal anesthesia technique, i.e., transforaminal sacral approach under C-arm guidance with a successful outcome. The sacral foraminal subarachnoid block is a method to access the subarachnoid space through the upper posterior sacral foramina.

The purpose of this study was to investigate the cutaneous nerves at risk during the posterior midline approach to the elbow and proximal ulna. Ten fresh frozen cadaver upper extremities were used for this study. A posterior midline skin incision extending from 10 cm proximal to 15 cm distal to the olecranon tip was created. All superficial nerves were identified and preserved. Nerve diameters were measured, their distance from the olecranon tip assessed, and they were dissected proximally to confirm their nerve of origin. Point of nerve arborization to skin from the midline incision was quantified. An average of one confirmed nerve proximal and five distal to the olecranon tip were identified with an average diameter of 0.9 mm proximal and 1.3 mm distal to the olecranon. The largest nerves were typically located 2 cm proximal (range 7–46 mm) and 45 mm distal (range 9–135 mm) to the olecranon. The branches arborized into the skin an average of 5.2 mm lateral to the incision. All nerves joined the posterior medial antebrachial cutaneous nerve. The branches of the medial antebrachial cutaneous nerve are at risk with a straight posterior midline elbow incision, though the clinical significance of injury to these nerves at this location is unknown.

Background The influence of approach on outcomes of posterior nonfusion stabilization has not been described. This paper analyzes the influence of surgical approach on functional outcome with nonfusion stabilization. Methods We performed a prospective consecutive cohort outcome analysis of 88 patients who had undergone posterior nonfusion stabilization of the lumbar spine at 178 levels using the Dynesys system (Zimmer Spine, Inc, Warsaw, Indiana). Patients needing decompression (n = 42) were operated through a midline approach using microscopic laminotomy/foraminotomy with or without discectomy, followed by posterior nonfusion stabilization with Dynesys. None of the patients had a complete laminectomy. Patients not needing decompression (n = 46) underwent the procedure via the bilateral paraspinal muscle-sparing approach and were subsequently stabilized. Clinical and functional outcomes data were collected using the visual analog scale (VAS), Treatment Intensity Score (TIS), Oswestry Disability Index (ODI), and SF-36. Average follow-up was 18 months (range, 12–36 mo). Results All outcome measures in both groups showed significant improvement at last follow-up. Between the groups a significant difference was apparent in the reduction of the TIS when measured at 1 week and 6 weeks. The preoperative, 1-week, and 6-week values were 66, 48, and 40, respectively (P < 0.05), for the midline group and 80, 32, and 28 (P < 0.05) for the paraspinal group. This trend continued through 3 to 6 months after the procedure but did not reach statistical significance. In the paraspinal group, pain scores showed a nonsignificant trend toward lower values in the first month, compared with values in the midline group. Patients reported excellent to fair results, with the exception of three patients in the midline group and two in the paraspinal group, who rated the procedure as fair. Conclusions Significantly fewer patients required postoperative narcotics in the paraspinal group than in the midline group. This improvement in early outcomes suggests a significant early benefit to the less tissue-destructive muscle-sparing approach in posterior nonfusion stabilization procedures.

Objective: The lateral pteryonal (PT) and the fronto-lateral (FL) approaches to pediatric craniopharyngeomas don't allow for full exposure of third ventricle and retro-chiasmatic cisterns due to anatomical barriers. The bifrontal approach, however, enabling midline vision is too invasive. The unilateral[for full text, please go to the a.m. URL], 66. Jahrestagung der Deutschen Gesellschaft für Neurochirurgie (DGNC)

Objectives To compare the posterolateral Wiltse approach and conventional Midline approach in short lumbosacral fusions in terms of the angle of convergence of pedicle screws. Methods We retrospectively reviewed computed tomography (CT) images of 76 lumbar and sacral pedicular screws that had been placed using a conventional midline approach (CA) (n = 38) and a Wiltse posterolateral approach (WA) (n = 38). All patients underwent short lumbosacral fusions from L3 to S1 for degenerative spinal disease. Screws with a bone gap >4 mm in any direction, cases with previous pedicular implants, and those with coronal plane curves >20° were excluded. Results Considering all implants, the angle of convergence was 23.3° (±15.8). The mean angulation in the WA group was 29.3° (±9.7), whereas in the CA group it was 17.2° (±0.6). This difference was statistically significant (P < 0.05). Conclusions In short, lumbosacral fusion employing the Wiltse approach allowed placement of pedicle implants with more convergence than the conventional midline approach. The clinical relevance of this is unknown, and prospective randomized studies are needed to clarify this.

At present central neuroaxial blockade, e.g. subarachnoid blockade (SAB) or epidural blockade (EB), especially the former one, is widely used by the clinical anaesthesiologists due to its procedural simplicity, low cost & better physiological benefits and thus reduced complications than that of general anaesthesia (GA). Subarachnoid or epidural spaces can be traversed from the posterior aspect of the body either through a midline approach (MA) or a paramedian approach (PMA). There is another approach described as ‘lumbosacral puncture' or Taylor's approach, which actually is a variant of conventional paramedian approach. Theoretically, subarachnoid & epidural spaces can also be approached through the paravertebral foramen or even via an anterior intraoperative approach through the intervertebral discs1. The most common & popular technique is the MA. But the PMA (both conventional & Taylor's) is also a very easy & effective technique that can be practiced routinely as well as for some clearly indicated cases. The requirement for this procedure is the same as for the MA except having some ideas about the offmidline anatomy. Keywords: Blockade, subarachnoid; approach, paramedian. Journal of BSA, Vol. 19, No. 1 & 2, 2006 p.51-53